Outcome prediction by motor and pupillary responses in children treated with therapeutic hypothermia after cardiac arrest.
Outcome prediction by motor and pupillary responses in children treated with therapeutic hypothermia after cardiac arrest.
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DOI：
10.1097/pcc.0b013e3182196a7b
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发表时间：
2012-01
期刊：
影响因子：
--
通讯作者：
Ichord RN
中科院分区：
文献类型：
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作者：
Abend NS;Topjian AA;Kessler SK;Gutierrez-Colina AM;Berg RA;Nadkarni V;Dlugos DJ;Clancy RR;Ichord RN
临床神经系统体征被认为是小儿心脏骤停（CA）后不良结局的预测因素，在治疗性低温（TH）的情况下可能具有不同的预后价值。我们的目的是确定运动和瞳孔反应在CA后TH治疗的儿童中的预后价值。前瞻性队列研究。三级医院儿科ICU。CA后接受TH治疗的儿童。前瞻性招募了35名CA后接受TH治疗的儿童。由急诊内科医生和重症监护室床边护士进行检查。在复苏后、达到低温后1小时、低温最后1小时、达到常温后1小时、常温24小时和常温72小时后进行检查。主要结局是ICU出院时的不良结局，定义为出院时儿科脑功能分类（PCPC）评分为4-6分。次要结局为死亡（PCPC = 6）。对于所有受试者和未接受麻痹剂的受试者，检查反应与不利结局（如PCPC 4、5、6和PCPC 6）之间的关联以阳性预测值（PPV）表示。使用Fisher精确检验确定这些比较的统计学显著性。在所有检查时间和检查类别中，不利结局PCPC 4、5、6的PPV均高于PCPC 6。到体温正常的第24小时，运动和瞳孔反应缺失高度预测不利的结果（PCPC 4、5、6）（所有类别的PPV 100%且p<0.03），而在早期，预测值较低。运动和瞳孔反应缺失在更广泛的定义下比仅定义为死亡时更能预测不良结局。在低温期间和自主循环恢复后不久，运动和瞳孔反应的缺失不能预测不良结局，而一旦体温正常，运动和瞳孔反应的缺失则预测不良的短期结局。需要使用更强有力的短期和长期结果措施进行进一步研究。
Clinical neurologic signs considered predictive of adverse outcome after pediatric cardiac arrest (CA) may have a different prognostic value in the setting of therapeutic hypothermia (TH). We aimed to determine the prognostic value of motor and pupillary responses in children treated with TH after CA. Prospective cohort study. Pediatric ICU in tertiary care hospital. Children treated with TH after CA. Thirty-five children treated with TH after CA were prospectively enrolled. Examinations were performed by emergency medicine physicians and intensive care unit bedside nurses. Examinations were performed after resuscitation, 1 hour after achievement of hypothermia, during the last hour of hypothermia, 1 hour after achievement of normothermia, after 24 hours of normothermia, and after 72 hours of normothermia. The primary outcome was unfavorable outcome at ICU discharge, defined as a Pediatric Cerebral Performance Category (PCPC) score of 4–6 at hospital discharge. The secondary outcome was death (PCPC = 6). The associations between exam responses and unfavorable outcomes (as both PCPC 4,5,6 and PCPC 6) are presented as positive predictive values (PPV), for both all subjects and subjects not receiving paralytics. Statistical significance for these comparisons was determined using Fisher’s exact test. At all examination times and examination categories PPV is higher for the unfavorable outcome PCPC 4,5,6 than PCPC 6. By normothermia hour 24, absent motor and pupil responses were highly predictive of unfavorable outcome (PCPC 4,5,6) (PPV 100% and p<0.03 for all categories), while at earlier times the predictive value was lower. Absent motor and pupil responses are more predictive of unfavorable outcome when defined more broadly than when defined as only death. Absent motor and pupil responses during hypothermia and soon after return of spontaneous circulation were not predictive of unfavorable outcome while absent motor and pupil responses once normothermic were predictive of unfavorable short-term outcome. Further study is needed using more robust short-term and long-term outcome measures.